INTRODUCTION
Access to contraception and termination of pregnancy (TOP) are two of the most low-cost and effective interventions that mediate improvements in women's health through a variety of ways, including reduced maternal mortality. Despite better access to healthcare and evidence-based medical interventions, maternal deaths remain unacceptably high in low- and middle-income countries.(1) The impact of contraceptive use has been quantified and is estimated to have cut the number of maternal deaths by at least 40% in the past 20 years in developing countries.(2)
It is generally accepted that the COVID-19 pandemic presents diverse challenges to health systems globally, with a disproportionate impact on those that are the lowest resourced at the outset.(3) Whilst South Africa is not necessarily on this end of the spectrum, and on the contrary invests a significant amount of its gross domestic product on health,(4) its history of fragmentation and inequities in the provision of healthcare has disadvantaged real progress in health systems performance, determinants of health and health status of its population.(5)
With the COVID-19 pandemic forecasted to continue, it is anticipated that the health system will be severely strained.(6) The need to balance routine healthcare provision with a robust COVID-19 pandemic response is continuously being echoed wherein countries have been cautioned to minimise disruptions in the provision of essential healthcare services and ensure their ability to respond to other health emergencies.(6) Threats to the provision of women's health services during COVID-19 have been documented in the United States and similarly during the Ebola outbreaks in West Africa. Analysis of trends in utilisation amongst clients using family planning services at the health district level before, during and after the Ebola outbreaks, indicated that reproductive health services were drastically affected by Ebola and resulted in decline in service utilisation.(7)
The declaration of the State of Disaster in South Africa due to the COVID 19 pandemic (on the 15th March 2020) and the subsequent imposition of a total national lockdown on all usual activities (from midnight 26 March 2020) galvanised both political and operational responses from the Gauteng Department of Health. Lessons from the recent Ebola outbreak in West Africa indicated that countries can avoid potential health systems catastrophes during epidemics as well as realise opportunities for longer-term health reforms.(7) The MEC for Health in Gauteng, expressed similar sentiments when he stated that: ‘COVID-19 is an opportunity to fast-track change and bring it closer: the acquiring and building of new hospitals and clinics and employing new doctors and nurses’, which he viewed as an opportunity to build resources that would have taken much longer to accumulate.(8)
The Disaster Management Act 2002 (Amendment of regulation 11B of the Regulations) stipulates that ‘Cabinet members responsible for health and social services’ need to prescribe which services will be necessary to preserve the delivery of essential health services. In addition to this, the President indicated that despite severe restrictions on people's movement, exceptions would be made to enable people to access essential services and urgent medical care. Health workers were at the top of the list of the categories of personnel who would continue to go to their workplaces.
‘Leave your home only if you need to get food and essential provisions, collect a social grant, buy medicine or get urgent medical care.’ (President Ramaphosa, 30 March 2020)
Despite these directives, there are indications that there have been impediments to access to reproductive health services. Reproductive rights are recognised as basic human rights and are entrenched within international laws and human rights documents. The Universal Declaration of Human Rights (1948) recognises the Right to Health, and specific reference is made to the right to reproductive health in the Convention on the Rights of Persons with Disabilities (2006). This can generally be applied to all women and should not be seen to be available exclusively to women in this vulnerable group. The Constitution of South Africa guarantees citizens’ rights to reproductive healthcare as part of the freedoms and rights to healthcare, food, water and social security which are upheld in the Bill of Rights.
Operationally, the potential occupational health risks to front line healthcare workers as well as health facilities becoming possible sources of COVID-19 transmission, prompted the Gauteng Department of Health to consider what constituted essential health services, especially at the primary care level.
The importance of unimpeded access to contraception and TOP, and evidence from other countries about how infectious outbreaks can adversely affect the provision of such services, prompted the authors to consider this question early in the COVID-19 pandemic in Gauteng.
METHODS
Study design and setting
This is a secondary data analysis of routinely collected health information from across all health facilities in Gauteng province in the District Health Information Service (DHIS) repository.
Data are reported daily from the five health districts which are the health administrative units for the delivery of primary healthcare services in the province. There are a total of 426 public healthcare facilities which comprise fixed health posts and mobile facilities that serve a population of 15.2 million people across five districts, namely, Johannesburg Metro, Ekurhuleni, Tshwane, West Rand and Sedibeng. Additionally, secondary and tertiary hospital facilities also report on the TOP procedures.
Data collection
The DHIS is a routine management information system which aggregates anonymised data for monitoring of healthcare programmes and reporting by the province. Headcounts, family planning and TOP indicators were extracted from the database over the period 1 April 2018–30 April 2020. The approved 2017 National Indicator Data Set (NIDS) specifies that the client or patient is only counted once for each day that they appear at the facility, regardless of the number of services provided on that day. TOP indicators monitor access and provision of TOP services. Clients accessing TOP services are counted only in the designated facilities where the termination is performed and takes into account the trimester when the termination was performed. Given the routine nature of the collection of this information and the fact that no patient identifiers were accessed, an ethics waiver was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical).
Data analysis
These indicators were then exported into MS Excel whereby graphs were generated to visually determine trends in headcounts, contraceptive provision and TOP utilisation patterns over the two years, noting the onset of the lockdown. The couple year protection (CYP) measure monitors access to and utilisation of contraceptives to prevent unplanned pregnancies in a one-year time period and serves as a proxy indicator for contraceptive prevalence rate. The CYP is derived by summing all types of contraception used by couples to protect against pregnancy, including sterilisation, after multiplying each method by a standardised conversion factor of effectiveness for that method over a one-year period. The CYP rate is a calculation of the summed CYP divided by the total number of women aged 15–49 in the population and is expressed as a percentage.
RESULTS
Total headcount at primary healthcare facilities
Figure 1 indicates the total primary care headcount for the period from April 2018 to April 2020. Year by year, over 21 million clients visited primary healthcare facilities in Gauteng. There were almost 500,000 fewer client visits to primary healthcare facilities during March and April 2020, compared to the pre-lockdown period, which represents an almost 30% decline in the total headcount. This is comparable to the Christmas holiday season when service uptake is the lowest as people leave Gauteng and return to their home provinces or countries.
Contraceptive methods uptake
The uptake of provider-dependent contraceptive methods shows a decline throughout April 2018 through April 2020, with the particular decline noticed before the lockdown period in February 2020 (Figure 2). Uptake of oral contraceptive pills (OCPs) has been increasing over the past two years, with a 30% increase in the use of this contraceptive method in April 2020 compared to the same period in 2018 and 2019. The uptake of injectable hormonal contraceptives (norethisterone enanthate and medroxyprogesterone acetate) is higher than all other available family planning methods besides OCPs. While the average monthly uptake of both injectables was 26,770 in April 2020, this represents a 45% reduction of the monthly average over the previous two years from almost 60,000 users. There also appears to be a preference for administration of the two month as opposed to the three-month injection. Male sterilisation or vasectomy as a contraceptive option was provided to only one client over the two years (in April 2019). The number of female sterilisations performed monthly remained stable including through the lockdown period. On average, 640 women accepted female sterilisation in April 2020, which is 97% of the average monthly uptake over the previous two years. A reduction to 48% in average uptake of subdermal hormonal implants and a slight decline (10%) for the intrauterine contraceptive device (IUCD) were noticed during the post lockdown period, compared to the average uptake in the previous two years.
Contraceptive method mix
The predominant contraceptive method dispensed by health facilities shifted to the prescription of OCPs over the study period. As seen in Figure 3, the uptake of OCPs was 36.2% in April 2018, increasing to almost 55% in April 2019 and 71% in April 2020. However, a closer look at the contraceptive mix between January 2020 and April 2020 indicates that almost 20% of the increase in OCP uptake occurred between February and April 2020, with near similar rates between April 2019 and January 2020. Of note is the limited uptake of permanent and longer-duration contraceptive methods, with male and female sterilisation, IUCD insertion and hormonal implants accounting in total for a maximum 2% of all family planning dispensed at health facilities, which occurred in April 2019.
CYP rate
The CYP rate began to decline one month before the national lockdown commenced in March 2020. The CYP rate generated during April 2020 was only 22.8% compared to 47.1% and 47.8% during the same reporting months in 2018 and 2019 respectively. The provincial CYP rate declined by almost 50% over the three months between February and April 2020 (Figure 4).
TOP services
A total of 1,507 TOPs were provided in health facilities in Gauteng in April 2020, out of which 1254 (83%) were conducted in the first trimester of pregnancy (0–12 weeks gestation) (Figure 5). This represents a 5% overall decline in the provision of abortion from April 2019 (1,591 vs. 1,507). Despite this decrease in the total number of abortions provided in April 2020 compared to April 2019, there was a 2% increase in the number of terminations performed in the first trimester, largely accounted for by the shift towards first trimester abortions in the districts of Tshwane and Ekurhuleni. Second trimester (13–20 weeks gestation) TOPs performed in April 2020 compared to the same period in the previous year showed a 17% overall decline.
Termination of pregnancies varied according to the different age groups with more TOPs performed in the age group above 20 years (Figure 6). By April 2020, however, these numbers had plummeted to near December 2019 levels, a decrease of about 30% from March 2020.
DISCUSSION
As the COVID-19 pandemic continues to evolve rapidly, we have highlighted the early impact that the pandemic and response by the province might be having on the access to and provision of contraception and TOP services in Gauteng province.
Evidence from previous pandemics has shown that their impact on reproductive health goes unnoticed because these effects are not as a direct result of the infection but instead are the consequences of strained health systems and disruption of services.(9) The lockdown restrictions that have been put in place by the government since March 2020 and the diversion of staff, including community health workers, and equipment for COVID-19 related needs, as well as population fears and anxiety, have indirectly and adversely affected the number of people attending healthcare facilities as well as the provision of contraceptive and pregnancy termination services in the province. Since demand-driven reproductive health services such as contraception and TOP services had started to decline during the month or so before and during the national lockdown due to COVID-19, the analysis to date has not been able to evaluate and quantify the real extent of the pandemic and lockdown restrictions. However, a notable decline in access and uptake of certain contraceptive technologies such as the two- and three-month hormonal injectables and increased prescription of OCPs just before the lockdown, could be attributed to the bulk stock of OCPs issued to facility pharmacies just before the lockdown, or that healthcare workers might have wanted to minimise contact time with clients. Unlike other forms of contraception, OCPs can be issued for months in advance reducing the need to visit health facilities; although, in this study, it is impossible to note the duration of supply that was dispensed.
This switching to less effective contraceptive methods, such as the OCP, and the persistent under-utilisation of methods with longer duration (IUCD, hormonal implants and sterilisation) may be an indication of either limited access to other choices, supply challenges and or limited information provision on the spectrum of contraceptive options. The cause of this trend needs investigation. We anticipate greater contraceptive failure rates, with subsequent increases in unintended pregnancies unless different strategies are adopted timeously. Such an increase in unintended pregnancies could slow down the province's efforts to achieve a reduction in maternal mortality to less than 100 per 100 000 at the end of the current financial year. The rise in first trimester TOP services in Tshwane and Ekurhuleni districts during the lockdown and onwards need critical attention especially in line with the unmet needs for contraception. Sharp declines in family planning visits and contraceptive use were also reported in Liberia, Sierra Leone and Guinea during the Ebola outbreaks and six months after the epidemic,(10,11) suggesting that the epidemic had sustained negative effects on reproductive health.
Contrary to expectation, we noted only a minimal decline in the provision of TOP services to adolescents (10–19 years) during the study period, which may be a possible correlation with school closure due to lockdown that might have contributed to the low incidence of unintended pregnancy in adolescent girls. However, indications are that services such as abortion care might have been temporarily scaled-down in most facilities within the province and this will likely have denied people access to such vital service.(12) Failure to access essential family planning methods and decline in CYP rates might have also contributed to unintended pregnancies and the reported shift to earlier abortions. Lockdown restrictions and scaled-down reproductive health services might force people to use backstreet and unsafe abortion services, which do not align with minimal required medical standards as recommended by the World Health Organization.(13) Evidence from previous pandemics such as the 2002–2003 severe acute respiratory syndrome (SARS) indicates that SARS was found to be associated with spontaneous abortion and other unintended health consequences.(14–16).
During the 2014 Ebola outbreak, access to reproductive health services was reported to have decreased in Sierra Leone, with reasons for the decline in help-seeking behaviour ranging from fear of contracting the disease, mandatory curfews, border closures and disruption of transportation routes that made obtaining medical services or continuing drug therapy challenging.(10) Similarly, the decline in the usage of reproductive healthcare services as indicated in this study could have devastating effects on population health if these services are not prioritised during the recovery phase. If reproductive health services continue to be adversely affected, the potential impact of COVID-19 could be far greater, become entrenched and probably reverse the gains in women's health that have been made over the past few decades.
Policy implications
To ensure the provision of essential reproductive health services, government together with other stakeholders such as civil society must continue to monitor and support reproductive services to ensure that people have access to family planning and safe abortion provision. Furthermore, as reproductive health services are a critical aspect of human rights, medical and social support and access to these services should be equitable and affordable to everyone including key populations, individuals with disabilities, adolescents, people living with HIV and those who are incarcerated.
Furthermore, there are lessons for Gauteng province and South Africa from the Ebola crisis to learn how to protect and ensure continuity of essential reproductive healthcare.(17,18) Context-specific solutions such as the family planning isolation wards which were set during the Ebola outbreak might need to be developed as COVID-19 cases continue to increase, to ensure that routine reproductive health services continue to be provided. The disruption and underutilisation of essential reproductive health services during this pandemic may require some facilities (community halls and unused buildings) within the Gauteng province to be repurposed to act as centres for the provision of such health services to avert potential reproductive health crisis such as unsafe abortion practices. Investing in community strategies as a primary source for the provision of essential reproductive health services including delivery of these services at people's homes might be one way to curtail serious health consequences that are bound to come with decreased access to such health services. Health workers who are involved in providing reproductive health services should be upskilled with an easy to access up-to-date evidence and be allowed to contribute to policy response discussions. The province should consider strengthening the regional supply of reproductive health commodities and pass guidelines that allow contraceptives to be provided even without a prescription. These strategies need to be supported by robust monitoring and evaluation systems to prevent diversion of resources and monitoring to see that vulnerable and marginalised populations are also being catered for.
LIMITATIONS
There may be some limitations owing to possible data incompleteness and the examination of only five weeks into the lockdown. We acknowledge that further epidemiological surveillance and investigations need to be carried out to understand the real impact of COVID-19 on the reported patterns.
CONCLUSION
This study provides early warning signs of the negative effect of COVID-19 on reproductive health-related indicators. The implication of our study indicates the need for accessible, equitable and affordable reproductive health services to mitigate negative health outcomes on people. Further research is needed to understand help-seeking behaviour by the population during the COVID-19 pandemic, the reasons behind switching contraceptive methods, the implications for TOP patterns for both younger and older women and potential opportunities that may arise because of the pandemic. While the current picture suggests a significant impact of COVID-19 on reproductive health, Gauteng can learn from other countries’ examples about how to provide high-quality reproductive health services during this pandemic. Acting swiftly to ensure improved accessibility of comprehensive package of reproductive health services remains critical if Gauteng province is to mitigate the indirect impact of COVID-19 on women's health.